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663 Beauchamp Rd , _� .' � � � ` , DAVIE COUNTY HEALTH DEPARTMENT � , Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990001044 Tax PIN/EH#: 5871-60-0361 Billed To: Dan Tullock Subdivision Info: Reference Name: Dan Tullock Location/Address: Beauchamp Road-27006 Proposed Facility: Residence Property Size: 17.535 Acrs ATC Number: 2368 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSiJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ,w'�!"yU�.aG(l��'�"� I' Date: ���,.��'�jJ� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. �QP� �—i�� � � �j �,r�� ���x 3c,o'�c r 2.. ►v' t Sa ' � _� S ��� ��c�S �. �.� F�o.vT- i a,-�k- ��kt-�. (c-2� Septic System Installed By: � �� Environmental Health Specialist's Signature: Date: �(��gl� DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ���'��'-dd • � �� , Environmental Health Section ` , P.O.Boz 848/210 Hospital Street , Mocksville,NC 27028 (336)75]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001044 Tax PIN/EH#: 5871-60-0361 Billed To: Dan Tullock Subdivision Info: Reference Name: Dan Tullock Location/Address: Beauchamp Road-27006 Proposed Facility: Residence Property Size: 17.535 Acrs **NO'i'�*'N'��iibgmprovem8ent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. i Residential Specification: Building Type #People� #Bedrooms � #Baths ,�Q,� ' Dishwasher: � Garbage Disposal: �� Washing Machine: � Basement w/Plumbing: � BasementJNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply-�* -�/ Design Wastewater Flow(GPD) �r� Site: New�Repair❑ /' System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width���Rock Depth,7� Linear Ft.� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 "BELOW FINISNED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m. on the day of installation. Telephone#is(336)751-8760.**** i I a � � . Environmental Health Specialist's Signature: �'�'-iti� ,-t�� -�', '.� , Date: �"�'��''�1� DCHD OS/99(Revised) -- -- - --- . � 6C� a�� - � � �� � � D . APPLICJ1T10N FOR SRE EVALUATION/IMPROVEMENT PERMIT&ATC ,�� 1 , Davie County Health Department t` 3 ^t�� Environmenta/Hea/th Section ✓ � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 - (336)751-8760 ***I1�ORTANT*** THIS APPI,ICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �C'1 1`� � (,L � ��C /� Contact Person ��I�1E Mailing Address �. (7_ �O �( �Y 7 6 Home Phone ��(p- 7 Sd R City/State/ZIP C�em m o Ns, N C , .Z ,� � 1 Buainess Phone 9 9 g� S�� / 2. Name on Permi.t/ATC if Different tbax� Akievs Mailinq lyddreas City/State/Zip 3. Application For: � Site Evaluation ,�Improvement Permit/ATC O�Both a. syst� to se�,rice: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. �f Residence: � People �_ � Bedrooms _�_ # Bathrooms � '�1. � Diahvasher � Gasbage Disposal � Washing Machine °�Basement/Plumbing , Basement/No Plumbing 6. If Susineas/Induatry/Other: SpaciPy type ii People # Sinka Y Commodea � Shoxera $ Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per a$y� 7. Type of water supply: �❑ ounty/Cit ❑ W _r ❑ Comm t I�UpU,� �Q re .t�✓ , :ua i S ru�i. j trP.�(�ho�c� ,'S Ue7�-�vA;�i�lb�,� a. Do you anticipate additions or egpahsions of the facility this system is inten ed to serve? ❑Yes Q�No If yes,w6at type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN M T BESUBMITTED the client with THIS APPLICATION. �,s.�J�i�c�P...�- Property Dimensions: Scc R�e I�e c� �V e WRITE DIRECTIONS(from Mocksville)to PROPERTY: TazOfficePIN: # J�$ �� � �PD- 03�� E�St' oN ( �g PropertyAddress: RoadNamel�akcl,A�� Qo�d SOc�, oa ���'�%Moit ��Q City/Zip �dU ANce , ��..�onG Le�.o a �Aac�nw,P/�d - Prr,�ae,. ;s If in a Subdivision provide information,as follows: j tc S f ►�!or'F�, e� �i N�i�rrt �}rrh g Name: Su6 0����s�o a , Section: Blcek: Lot: Date Property Flagged: �' �G-o D This is to certify that the information provided is correct to the best of my knowledge. �un�'erstaud t�eaR aa�y��rmit(s) issued hereafter are subject to suspensiou or revocation,if the site plans or intended use c6a�ge,or if�+h�entd���tion submitted in this application is falsified or changed I,also,understand that I am responsible jor all charges incu�red Jrom this application. I,hereby,give consent to t6e Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE mOlAfi�- I3� �-000 SIGNATURE A�v._I— THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge l��'Ac�1 mo�-�' � ' � S Sk r�c� O�/L�{P'( �i/'i�q� Date(s): (�'����,� i"' '1t � �5 AP*���. s k ow��+� s��� �j'►��''� Client Notification Date: Petcola�:�NS �ol.s w� e�.oruc . EHS; Account No. /� ��/ Revised DCAD(07/99) Invoice No. � �^ r .J � ' Porcel 2.01 � � I Tox Map E—S i� Eorl F. Myers � D.B. 112 — 440 � � 20 Lee Mock, Jr. ' Z^EiP •,• — 339 N 86'35'20"E � 0' o��e����oune 386.70' I N 72°03'20"E 20.89' L I � W I I/� � o �� ry / O � O I n � -. O ^ Z / U1 � \ r I o �F�P / � Parcel 3 o Ronald J. 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R••i ♦ •i. ��. •'' �•� ��_ •.�'� . �� �• •:.• I••'� , i : • '� s* . • : .� �.'•. .u. �� , .� !•1�'.•�' �� �w .� � �f�y'v�►i. �'• . a 0:•.,� � •' • • �•�'t•• �• � '• �"• �q .,��" !� �• ••� :'�- , •1,:I ♦�is�. ���.S""sis.�.'�.5....•4; . •�•'•� ..,'•�1,, f �V •! •s �•'• �., • ::•.a+��'' .��. r .•� !e' •�' � ��....1..��• '�'�• ��•' ��y, iR.'��:•.}a��• '� ' ��35.�t� , � � y « '�.-� .. � � '•�� .4-� � .� , '; . DAVIE COUNT'Y�ALTH DEPARTMENT � Environmental Health Section , � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001044 Tax PIN/EH#: 5871-60-0361 Bilted To: Dan Tullock Subdivision Info: Reference Name: Dan Tullock Location/Address: Beauchamp Road-27006 Proposed Facility: Residence Property Size: 17.535 Acrs Date Evaluated: ��_������ Water Supply: On-Site Well_D/ Community Public Evaluation By: Auger Boring f� Pit Cut �% FACTORS 1 2 3 4 5 6 7 Landsca e osition � 4. Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �- � Texture rou , Consistence i i Structure ,� ' �l Mineralo , / HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON . SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/99(Revised) ■����������■�■��■���■■■����■����■����■■■��■���■■�■��■■■■■■��■ ■■�■ ■������������■■�■�■���������■����■��■�■■■�■��■����■�■�■■��■■��■��i ■�����■����■■■■�■�■��■�����■■�������■�■��■��■����■�■��■■�����■�■ ■������■■■�������■����■■■■����■■ ■■���■■�■■■���■����������■ ■�■■■ ■■������■■■�■■�■�■�����■����■■�■���■��■■■�■■�����■����■■������■�■■ ■����■������■■■■�■��■����■■���■��■■��■�■■�■■��■��■■�■■■■■��■���■�■ ■■�������■�■■■■���■�■��■�■■���■■�■■��■��■�■■��■■��■�■■■��■�■■��■�■ ■�����■■■■�■�■�■■�■■A��■��■��■�■/■■��■�■■��■��■■�■��■■�■�����■■■�■ ■�■��■■��o��■■■�e�■■■����■■�������■��■����■■��■■■0■■■�■�■��■��■■�■ ■�■��■�■���■��■������■■■■�■��e����■■���■■�■���■����■■�■■■������■�■ ■�����■�t�■��■■����■■������■■��■��■■■��■����■��■���■�■■■���■��■■■ ■■■�■���■�■■����■���■■�■��■■�■�■ 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'� � �' � �AR 2 3 2010 o P�tai Street , ��� �i ' p�,,��,.� ouri r# : 09-40-06 ENVIROP�MEtJTRL NEALTH Mocks lle, NC 27028 � DAVIE COUNTY Phoue:(336)-753-6780 Fax:(336)753-1G80 ON-SITE WAST�WATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: ��r� 1�G L:L� 1 � "a c_,� Phone Number 3�`-���5' �a�'v (Home) Mailing Address:—�\�;� ��c.in ' l�.c.�... R� `�S��, - ��G-�3 SS`► (�orlc) �lc vc.�.c.� �v c. 2��v t� Ce i i DetailedD'uectionsToSite: �vc•,-� �d�-,(.s�•�1�, �u �� � �=�5�- , JVi�1,.� c�.� �(� � � rc�t,�- G r. �.����e s� � �'� �,�-�- �i .- '�'1 u c.�s ��w�-�.� �a �c,ln_�- o v. �e a�.��rti��Q Properiy Address: (, (� ?v c�c,t,�c c1 w.P . c�v ct�-.c.r� � N C..� � �-G C� 1�, Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: ��L r� �cn v�;e.\ �t�-�l� �� Type Of Facility: ���c,`e �c1�:1�., Date System Installed(Month/Date/Year): Nu v � a Cl d � Number Of Bedrooms: 3 Number Of People: � Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes �N ' If Yes,Explain: Please Fill In The Following Information About The NEW Facility: , Type Of Facility: S` in v�r'�o v4, Number Of Bedrooms: � Number of People � Requested By: � �\L.��1 Date Requested: 3 1 a-3 1 \0 (Signature) For Environmental Health Office Use Only Approved Disapproved _ { � j Comments: 3 _ O �l� � �'���1{�'\ y ; f �.� �. . _- Environmental Health Specialist Date: —� *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Z Amount:$ /011•G(1 Date: �3-Z,3/d Paid By: Received By: � Account#: ,�5�.t8' Invoice#: Zz�/